Susan M. Blake

Developing Theory-Based Substance Abuse Prevention Programs for Young Adolescent Girls

Considerable progress has been made in prevention science, and since reaching a high in the late 1970s and early 1980s, overall substance use has declined in the United States. However, for some populations and substances, smaller declines or even increased use has been observed. Notably, the traditional gender gap in substance use has decreased substantially, and it has disappeared completely for some substances, especially among younger cohorts. This article was written to integrate existing evidence on the relevance of gender for substance use prevention research and to move the field forward by suggesting theoretical models that might inform future prevention research with girls. This article reviews the following: (a) trends in substance use, (b) gender differences in risk factors, and (c) theoretical models deemed relevant to substance use prevention among girls. Finally, recommendations regarding needed research and prevention strategies that take gender, race, and ethnicity into account are provided.

A Review of Substance Abuse Prevention Interventions for Young Adolescent Girls

Consideration of the role of gender in alcohol, tobacco, and drug use, for the most part, has been omitted from studies of intervention effectiveness. Consequently, although scientists now can state with confidence that effective prevention approaches exist, it is not clear whether those programs are effective specifically for girls. Consequently, although great strides have been made in identifying substance use patterns, precursors to use, and effective prevention strategies in general, many questions remain about the ways in which those prevention efforts might address better the needs of differing gender and racial/ethnic groups. The primary goal for this report was first to review evidence of the effectiveness of traditional alcohol, tobacco, and drug use prevention approaches with girls and with boys, as well as available evidence from gender-specific or genderinformed interventions focused specifically on girls, and second, to make recommendations regarding needed research and prevention strategies that take gender into account.

Reducing Psychosocial and Behavioral Pregnancy Risk Factors: Results of a Randomized Clinical Trial Among High-Risk Pregnant African American Women

OBJECTIVES We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence). METHODS Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up. RESULTS Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021). CONCLUSIONS In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women

BackgroundAfrican American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.MethodsSix academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.ResultsForty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended ≥ 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.ConclusionWhile implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

An intervention to reduce environmental tobacco smoke exposure improves pregnancy outcomes.

OBJECTIVE: We tested the efficacy of a cognitive-behavioral intervention in reducing environmental tobacco smoke exposure (ETSE) and improving pregnancy outcomes among black women. METHODS: We recruited 1044 women to a randomized, controlled trial during 2001–2004 in Washington, DC. Data on 691 women with self-reported ETSE were analyzed. A subset of 520 women with ETSE and salivary cotinine levels (SCLs) of <20 ng/mL were also analyzed. Individually tailored counseling sessions, adapted from evidence-based interventions for ETSE and other risks, were delivered to the intervention group. The usual-care group received routine prenatal care as determined by their provider. Logistic regression models were used to predict ETSE before delivery and adverse pregnancy outcomes. RESULTS: Women in the intervention were less likely to self-report ETSE before delivery when controlling for other covariates (odds ratio [OR]: 0.50 [95% confidence interval (CI): 0.35–0.71]). Medicaid recipients were more likely to have ETSE (OR: 1.97 [95% CI: 1.31–2.96]). With advancing maternal age, the likelihood of ETSE was less (OR: 0.96 [95% CI: 0.93–0.99]). For women in the intervention, the rates of very low birth weight (VLBW) and very preterm birth (VPTB) were significantly improved (OR: 0.11 [95% CI: 0.01–0.86] and OR: 0.22 [95% CI: 0.07–0.68], respectively). For women with an SCL of <20 ng/mL, maternal age was not significant. Intimate partner violence at baseline significantly increased the chances of VLBW and VPTB (OR: 3.75 [95% CI: 1.02–13.81] and 2.71 [95% CI: 1.11–6.62], respectively). These results were true for mothers who reported ETSE overall and for those with an SCL of <20 ng/mL. CONCLUSIONS: This is the first randomized clinical trial demonstrating efficacy of a cognitive-behavioral intervention targeting ETSE in pregnancy. We significantly reduced ETSE as well as VPTB and VLBW, leading causes of neonatal mortality and morbidity in minority populations. This intervention may reduce health disparities in reproductive outcomes.

An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum. METHODS: Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum. RESULTS: The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5–31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7–43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25–2.75, number needed to treat=7, 95% CI 4–19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15–2.22, number needed to treat=9, 95% CI 6–29). CONCLUSION: An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381823 LEVEL OF EVIDENCE: I

Challenges in the Evaluation and Implementation of School-Based Prevention and Intervention Programs on Sensitive Topics:

The current emphasis on best practices for school-based health and mental health programs brings with it the demand for evaluation efforts in schools. This article describes the challenges of launching a successful school program and evaluation, with lessons learned from three projects that focus on intimate partner violence. The authors discuss issues related to constraints on the research design in schools, the recruitment of schools and participants within schools, program and evaluation implementation issues, the iterative implementation-evaluation cycle, and the dissemination of programs and study findings. The authors emphasize the need for flexibility and cultural awareness during all stages of the process.

Pregnancy Intentions and Happiness Among Pregnant Black Women at High Risk for Adverse Infant Health Outcomes

CONTEXT Unintended pregnancy is associated with risk behaviors and increased morbidity or mortality for mothers and infants, but a womans feelings about pregnancy may be more predictive of risk and health outcomes than her intentions. METHODS A sample of 1,044 black women who were at increased risk were enrolled at prenatal care clinics in the District of Columbia in 2001-2003. Bivariate and multivariate analyses assessed associations between pregnancy intentions or level of happiness about being pregnant and multiple psychosocial and behavioral risk factors, and identified correlates of happiness to be pregnant. RESULTS Pregnancy intentions and happiness were strongly associated, but happiness was the better predictor of risk. Unhappy women had higher odds than happy women of smoking, being depressed, experiencing intimate partner violence, drinking and using illicit drugs (odds ratios, 1.7-2.6). The odds of being happy were reduced among women who had other children or a child younger than two, who were single or did not have a current partner, who had had more than one sexual partner in the past year and who reported that the babys father did not want the pregnancy (0.3-0.6). In contrast, the odds of being happy were elevated among women who had better coping strategies (1.03), who had not used birth control at conception (1.6) and who had 1-2 household members, rather than five or more (2.1). CONCLUSIONS Additional psychosocial screening for happiness about being pregnant and for partner characteristics, particularly the fathers desire to have this child, may help improve prenatal care services and prevent adverse health outcomes.

Environmental Tobacco Smoke Avoidance Among Pregnant African-American Nonsmokers

BACKGROUND Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women. METHODS From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001-October 2003), cotinine-confirmed nonsmokers with partners, household/family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS avoidance. Data were initially analyzed in 2004. Final models were reviewed and revised in 2007 and 2008. RESULTS Twenty-seven percent of pregnant nonsmokers were confirmed as ETS avoiders. In multivariate logistic regression analysis, the odds of ETS avoidance were increased among women who reported household smoking bans (OR=2.96; 95% CI=1.83, 4.77; p<0.0001), that the father wanted the baby (OR=2.70; CI=1.26, 5.76; p=0.01), and that no/few family members/friends smoked (OR=3.15; 95% CI=1.58, 6.29; p<0.001). The odds were decreased among women who had a current partner (OR=0.42; 95% CI=0.23, 0.76; p<0.01), reported any intimate partner violence during pregnancy (OR=0.43; 95% CI=0.19, 0.95; p<0.05), and reported little social support to prevent ETS exposure (OR=0.50; 95% CI=0.30, 0.85; p=0.01). Parity, emotional coping strategies, substance use during pregnancy, partner/household member smoking status, and self-confidence in avoiding ETS were significant in bivariate, but not multivariate analyses. CONCLUSIONS Social contextual factors were the strongest determinants of ETS avoidance during pregnancy. Results highlight the importance of prenatal screening to identify pregnant nonsmokers at risk, encouraging household smoking bans, gaining support from significant others, and fully understanding the interpersonal context of a womans pregnancy before providing behavioral counseling and advice to prevent ETS exposure.

HIV Prevention Community Planning: Challenges and Opportunities for Data-Informed Decision-Making

The use of data in decision-making by the Massachusetts Prevention Planning Group (MPPG) wasassessed using multiple methods: in-depth interviews, member surveys, directed observations, and archival review. Three factors known to influence group decision-making were of interest: (1) member characteristics, (2) group structure, and (3) data inputs. Membership characteristics were not related to reliance on data. However, group structure factors and data inputs were directly related to reliance on data. Most members accepted an advisory role and felt participation was worthwhile. About half were dissatisfied with decision-making processes, citing member conflicts and distrust. Incompleteness of data, inadequate presentation quality, and lengthy intervals between presentations and actual decision-making were identified as deficits. Although most members reported skills with HIV- and intervention-related data, most also reported deficiencies in interpreting evaluation and cost-effectiveness studies. Member trust and use of data in decision-making could be improved by clarifying decision-making structures and processes, assuring high-quality data presentations, and supporting or training members to better interpret and use data.